wilkinsgraded-week4clinicalhomework

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Student’s Name: Jessie Wilkins Date: 6/12/15

SLCC Physical Therapist Assistant Program – Weekly Patient Progress Note Assignment

Daily Treatment Notes for Week (25 points/daily note, total of daily notes/number of daily notes= average out of 25 points):____________

Date:6/8/15

Change of orders by doctor: N/A

Contraindications: L bicep tear, Do not pull pt. up by arms or do heavy resistive exercises w/ L arm.

Precautions: O2 prn. (The chart only says this and we do not have pt. on O2 now so I do not know how many L). Wear gloves when working in pt. room. OA in R knee – do fewer reps w/ higher weight. Previous chest pain and CAD. Use right knee brace and L AFO during gait training.

Patient’s medical status: Pt. is pleasant, cooperative, oriented and able to make needs known.

S: N/A (Instead of n/a, you can write: “no new comments” or something to that effect). No new comments.

O: Gait trg: with FWW, training in correct hand/foot placement during gait and self-correction of posture during task performance. Pt. ambulated 240 ft. w/ 3 seated rest breaks. Patient demonstrated step to gait pattern with R foot until instructed by therapist to step through w/ R foot. Patient needed verbal cues to heel strike and straighten knees in stance phase of gait. Ther Ex: seated contract/relaxation therapeutic exercises to stretch hamstrings, and seated manual ankle plantar flexor stretch.

A: Patient is consistently ambulating 2x per day and shows potential to continue to increase strength and technique in functional ambulation. Techniques patient has demonstrated improvement in are consistently performing a heel to toe gait pattern and self-correction of posture during ambulation. Patient continues to respond well to stretching of flexors by demonstrating improved full body extension in posture during

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standing and gait.

P: Continue PT POC: Facilitate and increased step length for patient during gait training 2x tomorrow and static balance training at FWW to decrease risk of falls.

Problem(s) encountered by SPTA and outcome(s): N/A

Changes that need to be communicated to PT/nurse: N/A

Date: 6/9/15



Precautions: O2 prn. (The chart only says this and we do not have pt. on O2 now so I do not know how many L). Wear gloves when working in pt. room. OA in R knee –do fewer reps w/ higher weight. Previous chest pain and CAD. Use right knee brace and L AFO during gait training.


S: Pt. reported 7/10 knee pain with activity in R knee. Therapist performed MMT R dorsi flexion 4/5; L dorsi flexion 5/5; R hip flexion 3/5; L hip flexion 4/5. (MMT results go in O).

O: Gait trg: gait training to normalize gait pattern, adjustment of center of mass over BOS and safety training w/ larger steps and changing directions. Therapeutic Activities: transfer training to increase functional task performance and strengthening activities to increase functional task performance (seated: LAQ w/ ankle weights, marches w/ ankle weight on L, SLR). Neuro Re-Ed: and static standing balance training, facilitation of weight shift/dynamic stability and adjustment of center of mass over base of support, static balance training with UE activities and UEs crossing midline. Therapist performed MMT R dorsi flexion 4/5; L dorsi flexion 5/5; R hip flexion 3/5; L hip flexion 4/5.

A: Previously pt. needed Mod A to perform R hip flexion through full excursion, but has demonstrated increased strength by only needing Min A.

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Patient still demonstrates LE muscle weakness with MMT, step to gait pattern 35% of the time and short stride length. Pt. is cognizant of these corrections to gait that he needs to make but requires continued practice. He continues to be a high fall risk as pt. needs mod A for righting reactions w/ throwing/ catching activities but was able to stay standing w/o knees giving out for ~ 5 min. Patient requires further skilled interventions in order to increase his independence and safety with all functional mobility and balance.

P: Continue PT POC including gait training 2x a day w/ emphasis on safety and weight shifting.



Date: 6/10/15





S: Pt. reported low back pain of 7/10 today when on the total gym. Pt. (around age 89) and that he feels LBP when sitting or lying down.

O: Gait Trg: gait training with FWW w/ emphasis on stride length and self-correction during task performance. Pt. needed moderate VC’s to reach back when sitting down and to shift weight fully over leg in stance phase in order to increase stride length. Ther Ex: closed chain kinetic exercises (total gym), and standing plantar flexor stretch (heels off edge of stair).

A: Patient does get discouraged periodically that he is “not doing as good as he should” and requires encouragement. Pt. requires 57 minutes of co-treatment w/ Occupational Therapy for gait and transfer training to ensure pt. and therapist safety as pt.’s R knee can give out on him w/o

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warning. Pt. requires increased education on how to perform quad sets w/ emphasis on straightening the knee. He is demonstrating improved gait quality with a supportive R knee brace and with a simple AFO which assists L dorsiflexion. He is showing improved functional strength w/ demonstration of sit to stand w/ CGA. He continues to be a high fall risk and requires further skilled interventions in order to increase his independence and safety with all functional mobility and balance.

P: Continue PT POC including gait training 2x/ day. Focus on measuring distances between seated rest breaks.



Date: 6/11/15

Change of orders by doctor: Pt. must walk two times a day.




S: Pt. stated he did not sleep well last night due to back itching. Pt. stated R knee pain is at a 3-4/10 today and at a 9/10 when it “gives”. MMT L hip ABD 1/5 and R hip ABD 0/5.

O: Gait training using FWW and w/ emphasis on stride length. Patient needed verbal cues to take larger steps, shift weight from one foot to the other, and straighten knees in stance phase. Distance between seated rests was measured today, 23 ft., 15 ft., 8ft., 79 ft. Therapeutic Activities: facilitation of postural control, training in rolling, scooting, bridging to facilitate (I) bed mobility and transfer training to increase functional task performance. Ther Ex: open and closed chain kinetic exercises, bridging, straight leg raises and knee extension in supine and clam shells in side-

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lying. (2x15 of each exercise)

A: Patient demonstrated hip ABD weakness by MMT and by inability to fully weight shift in standing which is decreasing pt.’s stance phase and shortening stride length. Patient is increasing (I) to Min A in bed mobility. Patient was able to have 80% carryover of technique in LE ex’s due to new learning. Patient continues to participate in gait training 2x/ today and demonstrates good potential to continue to progress with further skilled interventions.

P: Continue PT POC: practice car transfer when daughter brings car. Address isolated LE weaknesses by doing isolated LE exercises for hip flexion, hip ABD, and hip extension (to facilitate proper functional gait kinematics). Continue to measure the distance between seated rests during ambulation.

Problem(s) encountered by SPTA and outcome(s): Pt. had a hard time getting his body to understand the quad set and straighten knee joint instead of bending it even when therapist was using verbal and tactile cues. SPTA will need to come up w/ a different approach to teaching this. (Yes, this can be a tricky one to explain and to get the desired result! Another tricky one is teaching posterior pelvic tilts!!!)


Date: 6/12/15



Precautions: O2 prn (Are you guys using O2 at all during his treatments anymore? What about at rest? Is he still using O2 at all?). Patient is no longer using O2 at all, so I should take this off now that it is no longer a precaution. (The chart only says this and we do not have pt. on O2 now so I do not know how many L). Wear gloves when working in pt. room. OA in R knee –do fewer reps w/ higher weight. Previous chest pain and CAD. Use right knee brace and L AFO during gait training.


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S: Pt. stated 7/10 aching pain in L hip today and that he liked the exercises we did today.

O: Gait Trg: gait training to normalize gait pattern, adjustments in velocity and directional changes. Patient needed minimal verbal cues for corrections today. Therapeutic Activities: strengthening activities to increase functional task performance and sit to stand transfer training to increase functional task performance. Patient is able to lock w/c breaks on own w/o verbal cues and needs CGA to perform sit to stand. Ther Ex: lower extremity (LE) therapeutic exercise 3x15 sets including: straight leg raises and knee extension in supine, bridging, side lying clam shells w/ and w/o theraband, facilitation of standing abilities w/ strength ex and contract/relaxation therapeutic exercises for knee extension flexibility. Patient needed 50% VC’s and 35% tactile cues for ex’s.

A: Patient’s condition is improving as a result of skilled therapy services. Pt. demonstrated improved gait quality and kinematics today with increased step length and straighter knees in stance phase as compared to previously this week, good foot clearance, stepping through, good posture, and more normalized and even cadence. A slight Trendelenburg gait has been observed by therapist this week and is planned to be addressed by isolated hip ABD exercises. Patient still requires continued skilled interventions to decrease fall risk because he is not consistently demonstrating standing recovery when knee starts to “give” rather pt. is sitting down in w/c behind him but will not always have w/c behind him when going home. Patient requires further skilled interventions in order to increase independence and safety with bed mobility, functional transfers, gait, static and dynamic standing balance, and increase functional activity tolerance. He demonstrates good potential to continue to progress with further skilled interventions.

P: Continue PT POC focusing on dynamic standing balance activities, and standing and seated hip ABD exercise due to pt. not able to ABD hip against gravity at this time. By patient request, work on gait in // bars w/ emphasis on straightening knee. While in // bars work on static standing balance.



Great notes this week, good improvement :) Thanks!!!

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Summary of Weekly Patient Progress Note(s)

Rationale for Daily Plan of Care (75 points):

*Note: Summarize daily treatment notes within each square.

Modalities Used:

N/A

Why Selected?

N/A

Outcome(s):

N/A

Progression (If no change, why?)

N/A

Therapeutic Exercises (Medicare # 97110):

1. Straight leg raises and knee extension in supine

2. Standing plantar flexor stretch (heels off edge of stair).

3. Side lying clam shells w/ and w/o theraband.

Why Selected (muscle exercise directed to and why)?

1. To gain the strength and motor control to improve gait quality, specifically functional knee extension in stance phase.

2. Facilitate ROM for proper toe clearance in swing phase of gait.

3. To increase strength of hip external rotators, to try and gain carryover of piriformis and posterior fibers of glut med strength for hip ABD. Hip ABD strength is needed to promote better stance phase in gait.

Provided Outcome(s):

1. Pt. was able to perform this exercise with better technique (straighter knees) this week than in previous weeks w/ no tactile assistance. Patient is consistently showing carry over w/ functional knee extension as ROM permits in gait this week.

2. Pt. consistently demonstrated heel to toe gait pattern this week.

3. Patient satisfaction feeling the muscles work. This is a new exercise and therapist will continue

Explain Progression (If no change, why?)

1. No change, patient is still getting proper technique.

2. Add manual resistance or theraband resistance.

3. Theraband to increase resistance.

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to monitor patient for outcomes.

Neuromuscular Activities (balance activities for sitting, standing, etc.) (Medicare # 97112):

Facilitation of weight shift/dynamic stability and adjustment of center of mass over base of support, static balance training with UE activities and UEs crossing midline.

Why Selected?

To improve balance and decrease fall risk.


Patient has had no fall or LOB this week.

Progression and Why?

We went from throwing a ball in front of chest, to throwing a ball over head. By moving the ball farther away from center of gravity, patient’s balance was challenged more.

Therapeutic Activities (Bed mobility and transfers that includes assistive device if needed, assistance required, etc.) (Medicare # 97530):

Training in rolling, scooting, bridging to facilitate I bed mobility

Why Selected?

To facilitate safe and functional bed mobility and get patient into proper stretching positions. Pre-gait.


Patient is able to perform sit to stand w/ CGA.


Less (A) level, to help pt. increase strength in core, UEs and LEs.

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and transfer training to increase functional task performance.

Transfer training to increase functional task performance

Patient locking own w/c breaks

Gait (Include assistive device(s) if used, level of assistance needed, distance, gait abnormalities, etc.) (Medicare # 97116):

Gait trg: with FWW, training to normalize gait pattern, correct hand/foot placement during gait, adjustment of center of mass over BOS, safety training w/ emphasis on stride length, changing directions, and

Why Selected?

Dr.’s orders to walk 2x a day and to Facilitate return to home.


Pt. satisfaction, LE strengthening for functional mobility.

Patient is showing improved gait kinematics. (See 6/12/15 note assessment).


Increased distances.

Decreased rest breaks w/ therapist encouragement when pt.’s body starts to go into flexion to stand up straight and continue walking.

Progressions to increase patient independence and safety in functional ambulation.

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adjustments in velocity. Patient demonstrated step to gait pattern with R foot until instructed by therapist to step through w/ R foot.

Pt. is self-correcting posture 80% of the time this week and is more consistently clearing toe in swing phase. When pt. feels like he needs to sit down during ambulation, or knee is giving out, pt. is increasing ability to rest while standing instead of sitting with therapist encouragement.

Pt. needs consistent verbal cues and tactile cues to straighten knee in stance phase, and to shift weight fully over leg in stance phase in order to increase stride length. Pt. needed VC’s for safety

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to reach back when sitting down this week.

For specific distances, see daily notes above.

Other: Why Selected? Provided Outcome(s): Progression and Why?

Goals Met (3 points):

1. Pt. will walk 200 ft. w/ 3 rest breaks w/o LOB and 60% verbal cues.

2. Pt. will walk 2x a day for at least 100 ft. each session this week.

3. Pt. will demonstrate functional strength in ankle dorsi flexors by consistently demonstrating heel to toe gait pattern during gait training.

Date Accomplished:

1. 6/4/15

2. 6/1/15

3. The week of 6/8/15

New Goals Initiated (3 points):

1. Pt. will be able to ambulate 2x/ day for a total of 250 ft. per day w/ CGA and w/o LOB. (This goal was not met for 300 ft. so I changed the amount of feet and will appropriately measure next week.)

2. Pt. will exhibit normalized gait pattern while safely ambulating 100 ft. with SBA using (A) device on level surfaces and across various surfaces w/in residence w/o rest breaks and while maintaining good balance.

Date Initiated:

1. For the week of 6/8/15. Goal not met, continue for week of 6/15/15.

2. For the week of 6/15/15

3. For the week of 6/8/15. Goal not met, continue for week of 6/15/15.

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3. Pt. will demonstrate static balance in // bars, w/ hands off // bars and CGA for 1 minute.

Interventions that were beyond scope of work or knowledge as a SPTA (2 points):

I know the theory of contract relax stretching, but as I was performing it, CI taught me from her experience that it is better to perform this in very small increments of advancement as we increase the stretch. When applying contract/relax to a supine hamstring stretch, she also taught me to keep the other leg I am not stretching straight and flat against the plinth to keep the pelvis in anterior pelvic tilt to get the most stretch out of the hamstrings. (Good, and YES!)

wilkinsgraded-week4clinicalhomework

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